MethodsA phacoemulsification probe was introduced into the anterior chamber of rabbits' eyes through a limbal incision, and ultrasound oscillation was performed without emulsifying the lens. Rabbits were assigned to 4 treatment groups: (1) no treatment (controls); (2) only irrigation with a salt solution; (3) ultrasound only; and (4) ultrasound oscillations with a salt solution of 0.001M ascorbic acid. The corneas were immunohistochemically examined for oxidative stress using 8-hydroxy-2-deoxyguanosine (8-OHdG), apoptosis by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL) staining, and ultrastructural changes by electron microscopy. The lipid peroxide levels in the aqueous humor were also measured.

ResultsIn the ultrasound-only group, 8-OHdG–positive cells and TUNEL-positive cells were detected at 24 hours; necrotic cells were detected at 12 to 24 hours. Also, lipid peroxide levels were significantly increased at later times in the ultrasound group. Such changes were not observed in other groups.

Clinical RelevanceClinicians should be aware that free radicals associated with ultrasound oscillation can injure the corneal endothelial cells.

Figures in this Article

Phacoemulsification has become the most commonly used technique in cataract surgery. Although both the safety and surgical outcome of phacoemulsification have dramatically improved owing to recent technical advances, phacoemulsification-associated corneal injury still remains an important complication. Several factors have been postulated to cause the injury, including excessive duration of the phacoemulsification, trauma due to the impact of the lens nuclear fragments, air bubbles, and mechanical and heat damage. In addition, it has been well established that ultrasound oscillations in water induce acoustic cavitations, which lead to the thermal dissociation of water vapors into hydroxyl radicals and hydrogen atoms.1 In fact, some experimental studies in ophthalmology have shown that phacoemulsification results in the formation of free radical species.2- 4 Using electron spin resonance analysis, we have also demonstrated the formation of hydroxyl radicals in the anterior chamber during phacoemulsification.5 In addition, there are some recent studies that have shown that the phacoemulsification-associated endothelial injury may be caused by free radicals.6- 9 Based on these findings, it seems likely that the corneal endothelium can be damaged by free radicals during phacoemulsification because free radical species, hydroxyl radicals in particular, are highly reactive and can cause lethal injuries to cells.10 The purpose of this study was to investigate the effects of free radicals on the corneal endothelium with special emphasis on histologic and immunohistochemical analyses after performing ultrasound oscillation in the anterior chambers of rabbit eyes.

METHODS

ANIMALS

Male Japanese white rabbits, weighing 2.5 to 3.0 kg, were purchased from Saitama Experimental Animal Supply (Saitama, Japan). The animals were kept individually under standardized laboratory conditions and were given tap water and food ad libitum. The treatment and handling of the rabbits was in accordance with the Association for Research in Vision and Ophthalmology Statement for the Use of Animals in Ophthalmic and Vision Research and the Nippon Medical School Animal Experiment Guideline.

ULTRASOUND OSCILLATION

The rabbits were anesthetized with an intravenous injection of pentobarbital (30 mg/kg), and topical oxybuprocaine hydrochloride was used for local anesthesia. A limbal incision was made with a disposable 3.0-mm surgical blade, and the phacoemulsification probe (Prestige; AMO, Santa Ana, California) was introduced into the center of the anterior chamber through the incision without touching any ocular structures. The phacoemulsification probe was used only to create the ultrasound oscillation, but the lens was not emulsified. The ultrasound oscillations were performed for 30 seconds at 100% power with continuous irrigation (25 mL/min) with Balanced Salt Solution (BSS) Plus (Alcon Laboratories Inc, Fort Worth, Texas). In an earlier study, we showed that hydroxyl radicals were generated under these conditions.5

The rabbits were assigned to 1 of 4 treatment groups: (1) no treatment (control group); (2) only BSS irrigation; (3) ultrasound oscillations and BSS irrigation; and (4) ultrasound oscillations and irrigation with BSS containing 0.001 M of ascorbic acid. At 15 minutes; 3, 6, 12, 24, 36, 48, and 72 hours; and 1 week after treatment, the rabbits were euthanized with intravenous sodium pentobarbital (65 mg/kg), and the aqueous humor was collected using a tuberculin syringe with a 26-gauge needle. Special care was taken to avoid blood contamination. The aqueous humor was immediately frozen and stored at − 80°C. The corneas were then carefully removed. There were 4 to 7 rabbits for each time in each group.

IMMUNOHISTOCHEMISTRY

The excised corneas were fixed in paraformaldehyde, 4%, overnight at 4°C, washed 5 times for 10 minutes each in phosphate-buffered saline (PBS), and treated with acetone for 5 minutes. They were then washed 3 times for 10 minutes each in PBS, incubated in proteinase K (20 μg/mL) for 30 minutes at room temperature, and then incubated in a 1:50 dilution of a monoclonal antibody against 8-hydroxy-2-deoxyguanosine (8-OHdG) (Japan Institute for the Control of Aging, Shizuoka, Japan), a marker of DNA damage by oxidative stress, overnight at 4°C. The corneas were then washed with PBS 3 times for 10 minutes and incubated with fluorescein isothiocyanate rabbit antimouse IgG (Zymed, San Francisco, California) for 1 hour at room temperature. Finally, they were washed with PBS 3 times for 10 minutes each and mounted on slides. The samples were examined with a fluorescence microscope.

Corneas were fixed overnight in paraformaldehyde, 4%, at 4°C. They were then washed 5 times for 10 minutes each in PBS, treated with acetone for 5 minutes, washed 2 times for 10 minutes in PBS, digested with proteinase K (20 μg/mL) for 30 minutes at room temperature, and washed 2 times for 10 minutes each in distilled water. The procedures followed the protocol supplied with the in situ apoptosis detection kit (Trevigen Inc, Gaithersburg, Maryland). The samples were equilibrated in terminal deoxynucleotidyl transferase–labeling buffer for 5 minutes and labeled with biotinylated nucleotide triphosphates using deoxynucleotidyl transferase for 1 hour at 37°C. The reaction was ended with deoxynucleotidyl transferase stop buffer for 5 minutes. The corneas were washed in PBS 3 times for 10 minutes and incubated with Fluorescein Avidin DCS (Vector Laboratories, Burlingame, California) for 1 hour. After washing 3 times with PBS, the samples were mounted on slides. The samples were examined with a fluorescence microscope.

SCANNING AND TRANSMISSION ELECTRON MICROSCOPY

Corneal tissues were fixed overnight in glutaraldehyde, 4%, postfixed in osmium tetroxide, 1%, and dehydrated through a graded alcohol series. For scanning electron microscopy, the tissues were freeze-dried using the t-butyl alcohol freeze-drying method,11 sputter coated with palladium platinum, and viewed with a S3000N microscope (Hitachi, Tokyo, Japan) operated at 20 kV. For transmission electron microscopy, the samples were embedded in glycerol polyglycidyl ether, and ultrathin sections were cut on an ultramicrotome with a diamond knife and stained with uranyl acetate and lead citrate. The sections were examined at 80 kV with a transmission electron microscope.

The concentrations of lipid peroxides in the aqueous humor were measured by the hemoglobin–methylene blue method described by Yagi,12 which selectively determines the absolute quantity of lipid peroxides and is specific for lipid peroxides. Statistical analysis of lipid peroxides was performed with a Mann-Whitney U test using SPSS software (SPSS Inc, Chicago, Illinois). P < .05 was considered significant.

RESULTS

IMMUNOHISTOCHEMICAL DETECTION OF 8-OHdG

None of the corneal endothelial cells from the rabbits in the control and BSS groups were 8-OHdG positive. In the ultrasound group, 8-OHdG–positive cells were also not present at 3 hours (Figure 1A) but were detected at 24 hours (Figure 1B). Cells positive for 8-OHdG were not observed at 48 hours. In the ascorbic acid group, there were no 8-OHdG–positive cells (Figure 1C and D).

Place holder to copy figure label and caption

Figure 1.

8-Hydroxy-2-deoxyguanosine (8-OHdG)–immunostained corneal endothelial cells. A, A cornea from the ultrasound group at 3 hours. There are no stained cells. B, Ultrasound group at 24 hours (8-OHdG–positive cells [arrows] are present). Nuclei and cytoplasm are stained. Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 3 hours (C) and 24 hours (D); there are no stained cells at either time.

The time course of detecting cells positive for terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) was similar to that for the 8-OHdG–positive cells. None of the corneal endothelial cells in either the control or the BSS groups were TUNEL positive. This was also true for the ultrasound group at 3 hours (Figure 2A). However, TUNEL-positive cells were present at 24 hours (Figure 2B); TUNEL-positive cells were not observed at 48 hours in the ultrasound group. In the ascorbic acid group, TUNEL-positive cells were not seen at any time (Figure 2C and D).

Place holder to copy figure label and caption

Figure 2.

Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL) staining of corneal endothelial cells. A, Ultrasound group at 3 hours. No TUNEL-positive cells can be seen. B, Ultrasound group at 24 hours; TUNEL-positive cells (arrows) are seen. Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 3 hours (C) and 24 hours (D); there are no TUNEL positive cells at either time.

ULTRASTRUCTUAL OBSERVATIONS

Scanning Electron Microscopy

In controls, the corneal endothelial cells were predominantly hexagonal, and the cell surface had microvilli and ruffled apical membranes in the periphery (Figure 3A). In the BSS group, a few microvilli were present at 24 hours (Figure 3B), but the sizes of the cells were almost uniform and were hexagonal, similar to the controls at all times. In the ultrasound group, a few empty spaces were observed in the corneal endothelial layer, and a few necrotic cells were seen at 15 minutes to 3 hours (Figure 3C). At 6 to 24 hours, the number of necrotic cells increased, and at 24 hours (Figure 3D), many microvilli were present on the endothelial cell surface. Afterwards, the number of necrotic cells was reduced. At 48 and 72 hours (Figure 2E), the cell sizes were different, and the density of microvilli was similar to that in the control group. In the ascorbic acid group, a few microvilli were present at 24 hours (Figure 3F), but the corneal endothelial cells were almost uniformly hexagonal, and there were no necrotic cells.

Place holder to copy figure label and caption

Figure 3.

Scanning electron micrographs of corneal endothelial cells. A, Control. Cells are predominantly hexagonal in shape and few microvilli are seen. B, Group treated with irrigation with a salt solution at 24 hours. A few microvilli are present. C, Ultrasound group at 3 hours. Empty spaces can be seen. D, Ultrasound group at 24 hours. Microvilli are present on the endothelial cell surface and some necrotic cells are seen. E, Ultrasound group at 72 hours. Cell sizes are different. F, Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 24 hours; there are no empty spaces.

Transmission Electron Microscopy

In controls, the shape of the nuclei were irregular with scattered heterochromatin. The cytoplasm had a well-developed rough endoplasmic reticulum and many mitochondria (Figure 4A). In the BSS group, the corneal endothelial cells appeared similar to those in the control group, and cell damage was not observed. In the ultrasound group, cell injury was already noted at 15 minutes with severe cellular edema at 3 to 6 hours. In the early period (15 minutes to 6 hours), some of the corneal endothelial cells appeared necrotic, the plasma membrane was damaged, organelles were swollen, and heterochromatin was not detected in the nuclei (Figure 4B). At 12 to 24 hours (Figure 4C), the nuclear membranes and lumen of the rough endoplasmic reticulum in the shrunken cells were swollen. The nuclei did not have heterochromatin condensation. The microvilli were extended and quite prominent. Early signs of necrosis were observed with the plasma membrane damaged, though many organelles and nuclei appeared normal (Figure 4D). At 48 and 72 hours (Figure 4E), the cells almost appeared normal, but there still was some cellular edema. In the ascorbic acid group, slight cellular edema was observed, but most of the cells appeared almost normal (Figure 4F and G).

Place holder to copy figure label and caption

Figure 4.

Transmission electron micrographs of corneal endothelial cells. A, Control (small arrows indicate mitochondria; large arrows, rough endoplasmic reticulum). B, Ultrasound group at 6 hours. Necrosis with plasma membrane damage, swollen organelles, and no heterochromatin in the nucleus (N). C, Ultrasound group at 24 hours. Nuclear membrane (arrows) and lumen of rough endoplasmic reticulum (asterisk) are swollen in shrunken cells. D, Ultrasound group at 24 hours. Early signs of necrosis with plasma membrane damage (far left side of the cell) are seen, but many organelles (right side) and nuclei appear normal. E, Ultrasound group at 72 hours. The cells are almost normal. F, Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 3 hours (F) and 24 hours (G). Slight cellular edema can be seen, but the cell almost appears normal.

Lipid Peroxide Levels in Aqueous Humor

The results of the lipid peroxide assays are shown in Figure 5. In the ultrasound group, lipid peroxide levels at 12 to 24 hours were significantly higher than those seen at 15 minutes to 6 hours (P < .05). Because corneal endothelial cells appeared almost normal histologically in the BSS and the ascorbic acid groups, we did not measure the lipid peroxide levels in these groups.

Place holder to copy figure label and caption

Figure 5.

Lipid peroxide levels in aqueous humor of the ultrasound group. Statistical analysis of the lipid peroxide levels was performed with the Mann-Whitney U test using SPSS software (SPSS Inc, Chicago, Illinois). There is a significant difference between the early (15 minutes to 6 hours) and the late (12-24 hours) stages (P < .05).

COMMENT

The results of this study clearly demonstrated that 1 of the causes of corneal endothelial damage by ultrasound is free radicals. One of the most commonly used markers for DNA damage by oxidative stress is 8-OHdG.13- 17 In our study, immunohistochemistry clearly demonstrated that 8-OHdG–positive endothelial cells were only found in the ultrasound group, which indicates that the induced DNA damage of the endothelial cells after ultrasound oscillation in the anterior chamber occurred because of free radicals. Also, because TUNEL-positive cells were only detected in the ultrasound group at times similar to those in the 8-OHdG–positive cells, we inferred an association between these 2 phenomena. Several studies have shown that oxidative stress can induce apoptosis in many kinds of cells.18- 22 The coincidence noted thereby strongly suggests that the apoptosis was induced by the oxidative damage caused by the free radicals.

The most important targets of free radicals are unit membranes, eg, plasma, mitochondrial, rough endoplasmic reticulum, and nuclear membranes. They can also act on DNA. Free radicals initiate toxic reactions at the plasma membrane and lead to cellular edema or necrosis.10,23,24 In our study, scanning electron microscopy showed alterations on the surface of the corneal endothelial cells while transmission electron microscopy demonstrated alterations in the fine structure of the cells. The cellular edema and necrotic cells with plasma membrane damage, swollen organelles, and absence of heterochromatin in the nuclei that were observed at the early stage (15 minutes to 6 hours) in the ultrasound group suggest that the free radicals produced by the ultrasound oscillation induced direct damage of the plasma membranes.

Cellular atrophy and necrosis were also found ultrastructurally in the late stage (12-24 hours) in the ultrasound group. In addition, 8-OHdG–positive cells were present only at 24 hours. Although typical apoptotic cells were not detected in the ultrastructural observations, TUNEL-positive cells were present immunohistologically at times similar to those seen for 8-OHdG. Thus, the alterations of the cells at the late stage were different from those at the early stage, indicating that there was a 2-phase pattern for injury in the ultrasound group. From in vivo studies, Pan and Sato25 reported that mild damage appeared in endothelial cells in the aorta during the early stage after hydrogen peroxide administration, with more extensive damage seen in the late stage. Zhang et al26 and Peters et al27 have reported that oxygen free radicals contributed to the ischemia/reperfusion damage in a 2-phase pattern in vivo. Their results suggest that the tissue damage induced by transient free radicals occurs in a 2-phase pattern, which supports our results.

The unsaturated bonds of cholesterol and fatty acids in the membranes can readily react with free radicals and undergo peroxidation. This process can become autocatalytic after initiation and will yield lipid peroxides. The loss of the fatty acids of cellular membranes, the formation of lipid peroxides, plus the uptake of oxygen by lipid-containing structures all suggest that peroxidation occurs. Thus, this leads to lipid peroxide–caused peroxidation once again, which enhances the cellular disorder.10,23,28 Lipid peroxides have a sufficient lifetime, which means that they can migrate and damage other cellular components, including DNA, apart from the membranes.29

The lipid peroxide levels at the later stage were higher than those at the early stage. In addition, 8-OHdG–positive cells, TUNEL-positive cells, and necrosis were detected in the later stage in the ultrasound group. These findings suggest that the latter phase of the corneal endothelial damage may be caused by the effects of lipid peroxides. Necrosis in the late stage may occur in the cells that have been damaged previously by lipid peroxides and at a time when the cellular edema from the early stage has yet to completely heal.

Some investigators have reported on the effect of the oxidative stress on the corneal endothelium by electron microscopic observations. Injection of hydrogen peroxide into the anterior chamber in vivo can cause swelling of the cytoplasm, disruption of the organelles in the corneal endothelial cells,30 shrinkage of the cells, and disruption of the intercellular junctions of the Descemet membrane.31 Riboflavin-UV-A–mediated exposure in vivo can induce chromatin condensation, apoptotic bodies, and shrinkage of endothelial cells.32 Reactive oxygen species associated with photosensitizers can induce apoptosis and necrosis in the corneal endothelium in vitro.33 However, to the best of our knowledge, there have not been any studies that have investigated the oxidative injury at different times, which would indicate that there is a 2-phase pattern for the damage in the corneal endothelial cells.

Ascorbic acid is a well-established antioxidant. Rubowitz et al6 have performed ultrasound oscillation in the anterior chambers of rabbit eyes while irrigating the chamber with a BSS of 0.001 M ascorbic acid. Their specular microscopic and histopathologic observations showed a 70% decrease in the number of corneal endothelial cell loss with irrigation with BSS containing 0.001 M of ascorbic acid compared with BSS-only irrigation. Their findings demonstrated that ultrasound oscillation in the anterior chamber can cause endothelial damages through free radical formation by using ascorbic acid as a scavenger. Because of their findings and because the natural concentration of ascorbic acid in human vitreous is approximately 0.001 M, we used the same concentration of ascorbic acid in the irrigating solution.34 In the ascorbic acid group, 8-OHdG–positive cells and apoptotic cells were not detected, and most of the cells were ultrastructurally normal at all times. These results not only support the findings of Rubowitz et al6 but are in fact due to the oxidative insult by the free radicals. In addition, our results suggest that the anti–free radical effects of the glutathione in BSS are not sufficient but that ascorbic acid (0.001 M) can counteract the oxidative insult by the ultrasound-induced free radicals. Earlier,35 we demonstrated by electron spin resonance analysis that ophthalmic visosurgical devices inhibit the effects of free radical formation. Therefore, clinicians should pay more attention to the retention of ophthalmic visosurgical devices in the anterior chamber during ultrasound oscillation.

In conclusion, we examined the corneal endothelial cell damage associated with ultrasound oscillation in the anterior chamber. The appearance of 8-OHdG–positive cells and the 2-phase pattern of damage indicate that the corneal endothelial cell can be damaged by transient production of free radicals. While other clinical insults—such as trauma by the impact of lens nuclear fragments, heat injury, air bubbles, or turbulence of the solution—can occur, clinicians should be aware of the effects of free radicals, as the oxidative stress can cause lethal damage to corneal endothelial cells.

Figures

Place holder to copy figure label and caption

Figure 1.

8-Hydroxy-2-deoxyguanosine (8-OHdG)–immunostained corneal endothelial cells. A, A cornea from the ultrasound group at 3 hours. There are no stained cells. B, Ultrasound group at 24 hours (8-OHdG–positive cells [arrows] are present). Nuclei and cytoplasm are stained. Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 3 hours (C) and 24 hours (D); there are no stained cells at either time.

Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL) staining of corneal endothelial cells. A, Ultrasound group at 3 hours. No TUNEL-positive cells can be seen. B, Ultrasound group at 24 hours; TUNEL-positive cells (arrows) are seen. Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 3 hours (C) and 24 hours (D); there are no TUNEL positive cells at either time.

Scanning electron micrographs of corneal endothelial cells. A, Control. Cells are predominantly hexagonal in shape and few microvilli are seen. B, Group treated with irrigation with a salt solution at 24 hours. A few microvilli are present. C, Ultrasound group at 3 hours. Empty spaces can be seen. D, Ultrasound group at 24 hours. Microvilli are present on the endothelial cell surface and some necrotic cells are seen. E, Ultrasound group at 72 hours. Cell sizes are different. F, Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 24 hours; there are no empty spaces.

Transmission electron micrographs of corneal endothelial cells. A, Control (small arrows indicate mitochondria; large arrows, rough endoplasmic reticulum). B, Ultrasound group at 6 hours. Necrosis with plasma membrane damage, swollen organelles, and no heterochromatin in the nucleus (N). C, Ultrasound group at 24 hours. Nuclear membrane (arrows) and lumen of rough endoplasmic reticulum (asterisk) are swollen in shrunken cells. D, Ultrasound group at 24 hours. Early signs of necrosis with plasma membrane damage (far left side of the cell) are seen, but many organelles (right side) and nuclei appear normal. E, Ultrasound group at 72 hours. The cells are almost normal. F, Group treated with ultrasound oscillations with a salt solution of 0.001M ascorbic acid at 3 hours (F) and 24 hours (G). Slight cellular edema can be seen, but the cell almost appears normal.

Lipid peroxide levels in aqueous humor of the ultrasound group. Statistical analysis of the lipid peroxide levels was performed with the Mann-Whitney U test using SPSS software (SPSS Inc, Chicago, Illinois). There is a significant difference between the early (15 minutes to 6 hours) and the late (12-24 hours) stages (P < .05).

Correspondence

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with
the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.

Indicate what change(s) you will implement in your practice, if any, based on this CME course.

Your quiz results:

The filled radio buttons indicate your responses. The preferred responses are highlighted

For CME Course:
A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes

Indicate what changes(s) you will implement in your practice, if any, based on this
CME course.

Instructions

Thank you for submitting a comment on this article. It will be reviewed by JAMA Ophthalmology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.

Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.

* = Required Field

Comment Author(s)* (if multiple authors, separate
names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.

This feature is provided as a courtesy. By using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to the AMA's Terms of Use. The information provided in order to email this article will not be shared, sold, traded, exchanged, or rented. Please refer to The JAMA Network's Privacy Policy for additional information.

Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.